A nurse is assessing a child who has heart failure. Which of the following findings is a clinical manifestation associated with this diagnosis?

- A: Tighten the screws on the halo device one-quarter turn every 48 hr.
- Rationale: This action is incorrect because the screws on a halo device should not be adjusted by the nurse. The screws are typically set and secured by a healthcare provider, and any adjustments can compromise the integrity of the device and the stability of the cervical spine.

- B: Assess the pin sites for infection once every other day.
- Rationale: While it is important to monitor the pin sites for signs of infection, doing so once every other day may not be sufficient. Pin sites should be assessed at least once per shift to ensure early detection and management of any potential infection.

- C: Encourage flexion and extension of the neck.
- Rationale: This action is contraindicated for a client with a halo vest. The purpose of the halo vest is to immobilize the cervical spine to promote healing. Encouraging neck movement could cause further injury or delay healing.

- D: Reposition the client using a turning sheet.
- Rationale: This is the correct action. Using a turning sheet helps to reposition the client safely and effectively without exerting unnecessary pressure on the cervical spine. It also aids in preventing pressure ulcers and promotes comfort for the client.

A. There is no need to seal soft toys in a plastic bag for 14 days as impetigo is not typically spread through inanimate objects. However, it is important to discourage the child from scratching the lesions to prevent further spread.

B. Soaking hairbrushes in boiling water is not necessary for the management of impetigo.
Impetigo is caused by bacteria, not lice, so boiling hairbrushes is not a standard recommendation for this condition.

C. This is the correct instruction. Applying a bactericidal ointment (e.g., mupirocin) to the impetigo lesions is a common treatment approach. This helps to eliminate the bacteria causing the infection and promote healing.

D. Administering acyclovir is not indicated for impetigo. Acyclovir is an antiviral
medication used to treat viral infections, such as herpes simplex virus. Impetigo is caused by bacterial infection, not a virus.